The present invention relates to electrosurgical apparatus for tissue ablation generally, and particularly to electrosurgical apparatus for radio frequency (RF) tissue ablation.
Radio frequency (RF) tissue ablation is a well-known technique for making thermal lesions in the vicinity of an uninsulated tip of an electrode due to tissue coagulation caused by resistive heating. The electrode can be applied directly on superficial structures, surgically, endoscopically, laparascopically, or even via a transcatheter access such as a treatment for symptomatic cardiac arrhythmias. If the electrode is formed as a needle, then the electrode may be inserted interstitially, and guided by imaging.
As is known in the art, resistive heating is proportional to the square of the current density, the latter being inversely proportional to the square of the distance from the ablation electrode. Therefore, resistive heating decreases from the ablation electrode with the distance to the fourth power. In other words, significant resistive heating only occurs within a narrow rim (of a few millimeters) of tissue in direct contact with the ablation electrode. Deeper tissue heating occurs as a result of passive heat conduction from that rim.
A general problem in RF tissue ablation is limitation in lesion size. Increasing the power to the electrode or exposure time to the tissue increases the amount of energy delivered around the electrode and thereby increases the lesion size. However, at high temperatures (e.g., above 100xc2x0 C.) at the electrode-tissue interface, the impedance increases significantly because of desiccation followed by charring around the electrode tip. This leads to an abrupt fall in lesion current (and delivered effect) and no further energy is delivered around the electrode, and no further tissue heating occurs. This phenomenon tends to limit lesion size in the transverse direction around the electrode. The longitudinal dimension of the lesion is basically dependent on the length of the uninsulated part of the electrode.
Tissue adhesion and limited lesion size are just two examples of problems associated with RF tissue ablation. Another problem occurs when attempting to ablate tissue in difficult-to-reach locations, such as the lower esophagus. It is difficult to control the depth of the ablation into the tissue and to obtain a uniform ablation over the entire surface area that needs to be ablated. Surface irregularities, folds into the tissue, and variations in the anatomical configurations of body cavities increase the difficulty of achieving uniform RF tissue ablation. As a result, only a portion of the tissue to be ablated may be destroyed, and in some areas, more tissue may be ablated than was intended.
Attempts have been made in the prior art to overcome the abovementioned problems. One known solution is that of xe2x80x9celectrolyte-assistedxe2x80x9d ablation. This form of ablation relies on contacting the tissue to be ablated with an electrolyte, such as a fluid or gel. Electrical energy is applied through the electrolyte to the tissue in contact with the electrolyte. Because the electrical resistance of the electrolyte-tissue interface is significantly high relative to the resistance of the electrolyte itself, most of the energy will be dissipated at this interface in the form of heat, leading to thermal ablation of the superficial tissue at this interface. Introduction of a conducting and/or cooling liquid into the treated area generally increases the coagulated volume and tends to reduce tissue adhesion. Electrolyte-assisted ablation is also effective in difficult-to-reach locations, because the liquid or gel electrolyte effectively bathes the entire surface area of the tissue that is to be ablated.
One example of electrolyte-assisted ablation is discussed in U.S. Pat. No. 6,112,123 to Kelleher et al., assigned to Endonetics, Inc., San Diego, Calif., USA, the disclosure of which is incorporated herein by reference. Kelleher et al. describes electrolyte-assisted tissue ablation of metaplasia in the esophagus by means of a shaft with an expandable barrier that is deployable from the shaft""s distal end. An electrode and a temperature/impedance sensor are mounted on the shaft. The shaft may be a catheter formed with several lumens that are used independently for housing optical elements and for transferring fluid.
In the operation of the device, the distal end of the shaft or catheter is placed in the esophagus proximal the cardia. The barrier is then deployed to the cardia and expanded to seal the esophagus from the stomach. The esophageal volume between the barrier and the catheter is partially flooded with a conducting medium and the electrode is deployed into the conducting medium. The sensor is also deployed into contact with the tissue to be ablated. Using open-loop control, or using temperature, impedance, or visual monitoring for closed-loop control, the metaplasia is ablated by passing RF energy from the electrode and through the conducting medium for contact with the tissue being ablated.
Kelleher et al. limits the RF power to a moderate level by using the closed-loop control, wherein the output of the temperature sensors near the electrode is used to control power delivery. However, a disadvantage of Kelleher et al. is that enlargement of the coagulated volume is at the expense of slower coagulation speed and prolonged treatment time.
Another example of electrolyte-assisted ablation is described in U.S. Pat. No. 5,348,554 to Imran et al., assigned to Cardiac Pathways Corporation, Sunnyvale, Calif., USA, the disclosure of which is incorporated herein by reference. Imran et al. includes a catheter constructed of an elongate member having proximal and distal extremities. A metal conducting electrode is secured to the distal extremity of the elongate member and has a chamber formed therein. A conductor extends through the elongate member from the proximal to the distal extremity for supplying RF energy to the electrode. The elongate member has a lumen in the distal extremity, which is in communication with the chamber. A coolant is disposed in the chamber and in contact with the electrode for dissipating heat created in the electrode by the application of RF energy thereto. A disadvantage of Imran et al. is that the coagulated volume is limited due to the relatively small diameter of the electrode used.
Other examples of cooled electrodes include U.S. Pat. No. 5,100,388 to Behl et al., which describes a catheter having a conductive material delivery lumen and a distal tip heating element, suitable for hollow body organs, such as the gall bladder. U.S. Pat. No. 5,304,214 to DeFord et al., describes an RF ablation device specifically designed to selectively ablate prostatic tissue about the prostatic urethra. The disclosures of these patents are incorporated herein by reference. A disadvantage of Behl et al. or DeFord et al. is that the structure of these devices is custom-made to fit a particular anatomy and is not generally suitable for any other anatomy in the body. They also suffer from limited coagulated volume that is possible with the electrode.
In order to overcome the limitation of the small coagulated volume associated with a fine linear needle electrode, U.S. Pat. Nos. 5,431,649 and 6,016,809 to Mulier et al., assigned to Medtronic, Inc., Minneapolis, Minn., USA, the disclosures of which are incorporated herein by reference, propose a hollow helical electrode, with injection of a cooled conducting liquid.
In general, Mulier et al. is directed to treatment of tachyarrhythmias, wherein one or more chambers of the heart exhibit an excessively fast rhythm. In particular, Mulier et al. is directed to treatment of tachycardias, which are due to the presence of ectopic foci within the cardiac tissue or due to the presence of aberrant condition pathways within the cardiac tissue. In Mulier et al., a catheter is provided with a hollow, helical electrode, which is screwed into cardiac tissue at a desired ablation site and connected to a source of RF electrical energy to ablate the tissue adjacent the electrode. Prior to ablation, it is essential to inject a conductive fluid through the hollow needle, which cools the tissue adjacent the needle and increases the conductivity of the tissue in the area of the electrode.
The helical electrode provides an enlarged surface area as compared to relatively straight or needle-like electrodes for insertion into the endocardium, and also serves to stabilize the location of the catheter during the application of the RF signal. In addition, there is essentially no bleeding following removal of the helical electrode, so it can safely be placed in multiple locations for mapping and ablation purposes.
Mulier et al. uses a non-toxic, non-arrhythmogenic, conductive solution such as Ringer""s solution to the area of the electrode, before and during application of RF energy. The helical electrode is hollow, and the conductive solution is applied through one or more apertures in the electrode. The conductive solution injected prior to application of the RF signal is believed to displace blood in the vicinity of the electrode. Ringer""s solution, for example, has a much higher conductivity than blood (approximately 3-4 times higher) or cardiac muscle (approximately 7 times higher). Overall resistance to the induced electrical current is reduced, which is believed to assist in expanding the size of the lesion, by spreading the effective area of application of the electrical current over a wider area. Application of the conductive solution during the burn helps prevent overheating of the tissue, allowing for a prolonged application of the RF signal, extending beyond the point at which burning or charring would otherwise normally occur.
However, liquid handling and adjusting the electrode length to that of the treated area are shortcomings, especially for a relatively large volume. Moreover, a monopolar helical electrode is limited in its ability to deliver power inside the helix and to control the treated boundary outside the helix. Furthermore, local temperature along a long electrode is generally difficult to control, because local temperature varies according to local variations of tissue impedance and current density.
U.S. Pat. No. 6,132,426 to Kroll, assigned to Daig Corporation, Minnetonka, Minn., USA, describes an RF ablation catheter that incorporates therein a positive temperature coefficient (PTC) temperature sensor. The PTC sensor provides a built-in fail-safe current limiter to avoid over-ablating the target tissue, and to prevent coagulation adherence to the catheter electrode tip and damage to the catheter and patient from overheating. However, disadvantages of Kroll include slower coagulation speed and prolonged treatment time.
Some prior art mentions rotation of the ablating electrode. For example, U.S. Pat. No. 6,010,476 to Saadat, assigned to AngioTrax, Inc., Sunnyvale, Calif., USA, describes a device for creating transmural channels for transmyocardial revascularization. The device includes a cutting head that may ablate or cut tissue with RF energy. The cutting head may be coupled to a drive tube and rotated at high speeds by a motor and gearing. However, the rotation of the cutting head is not used to prevent tissue adhesion, rather rotation is used to facilitate entry of the cutting head into the cardiac tissue and to help form transmural channels. Once the electrode has arrived at the desired location, RF energy is applied to the electrode to ablate tissue. Saadat does not mention ablating while rotating the electrode.
U.S. Pat. No. 6,066,134 to Eggers et al., assigned to ArthroCare Corporation, Sunnyvale, Calif., USA, the disclosure of which is incorporated herein by reference, describes an electrosurgical probe that includes a shaft having an electrode array at its distal end and a connector at its proximal end for coupling the electrode array to a high frequency power supply. The shaft includes a return electrode recessed from its distal end and enclosed within an insulating jacket. The return electrode defines an inner passage electrically connected to both the return electrode and the electrode array for passage of an electrically conducting liquid. By applying high frequency voltage to the electrode array and the return electrode, the electrically conducting liquid generates a current flow path between the return electrode and the electrode array so that target tissue may be cut or ablated.
Eggers et al. mentions manually reciprocating or rotating the probe in a light brushing motion, so as to maintain the supply of electrically conducting fluid in the region between the active electrodes and the tissue. The dynamic movement of the active electrodes over the tissue site is used by Eggers et al. to enable the electrically conducting liquid to cool the tissue surrounding recently ablated areas to minimize damage to this surrounding tissue. Eggers et al does not mention ablating while reciprocating or rotating the electrode. Moreover, the dynamic movement is not used by Eggers et al. to prevent tissue adhesion. Identical use of reciprocation of the probe during electrosurgical tissue revascularization is discussed in U.S. Pat. No. 6,102,046 to Weinstein et al., also assigned to ArthroCare Corporation, the disclosure of which is incorporated herein by reference.
The present invention seeks to provide novel electrosurgical apparatus for RF tissue ablation that solves the abovementioned problems of the prior art.
The electrosurgical apparatus of the present invention comprises a manipulator that moves electrodes in a controlled manner while RF power is delivered to the electrodes. Unlike the prior art, the RF electrode may ablate during controlled motion thereof. This motion helps prevent tissue-electrode adhesion. The motion may be unidirectional along the length of the treated volume, or alternatively may comprise reciprocating motion, vibration or combinations of different kinds of motion. The motion of the electrode is preferably along the electrode trajectory, i.e., linear motion for linear electrodes and helical motion for helical electrodes.
The electrode is at the distal tip of an electrically insulated support. The electrode may be monopolar or bipolar, hollow or non-hollow. The electrode may be linear or may be a short segment at the tip of a helical, insulated support. The electrode itself may be helical. For example, the electrode may be configured as a monopolar electrode, with a single or multiple-helix as the active (current emitting) electrode, or as a bipolar electrode with single or multiple helix-pairs. Alternatively, a bipolar electrode may comprise a single or multiple-helix as one electrode and a conducting central rod as the other electrode.
In one embodiment of the present invention, the electrodes are configured as a pair of bipolar concentric (sharing a common center) or eccentric (off-center) helices. A plurality of electrodes may be mounted on the same helical insulated support. A central insulated rod may be added to helical electrodes for motion stabilization. Additional possible electrodes configurations may be obtained by using straight needles instead of helices.
The helical electrode assembly may coagulate a cylindrical envelope of tissue, while at the same time sparing a cylinder of tissue at the center of the helix. For example, the helical arrangement may be used to coagulate prostate tissue around the urethra without causing coagulation of the urethra itself. In other treatment plans, it may be desirable to cause necrosis of the inner cylindrical volume of the helical electrode assembly. In such a case, the helical electrode assembly may coagulate the tissue surrounding the inner cylindrical volume in such a way such that the blood supply to the inner non-coagulated cylindrical tissue is cut off. The non-coagulated cylindrical tissue is then left to die due to the absence of a sufficient blood supply from the coagulated cylindrical envelope, thereby increasing the amount of tissue that undergoes necrosis and shortening treatment time.
The manipulator, controlled by a controller, preferably inserts electrodes into the tissue target site (X-direction) at a predetermined YZ position using linear and/or rotational motion. The manipulator may then impart reciprocating motion to the electrodes by reversing the insertion motion. The velocity of the electrode motion may be controlled in various manners, such as by an impedance measurement in a closed-loop fashion. The manipulator may translate the electrodes to a different YZ position prior to subsequent insertion. The electrode assembly may be disposable, and may be easily replaced and attached to the manipulator.
Treatment planning software, based on user interaction with a display of registered anatomical images obtained prior to the treatment, may generate a treatment plan that includes positioning and power delivery instructions to the controller and manipulator.
Imaging apparatus, mechanically or otherwise coupled to the manipulator, determines electrode position during intra-corporeal motion in order to facilitate power delivery according to the treatment plan.
There is thus provided in accordance with a preferred embodiment of the present invention electrosurgical apparatus including an electrode adapted to deliver radio frequency (RF) energy to a tissue, an RF energy source in communication with the electrode, a manipulator in operable connection with the electrode, adapted to move the electrode, and a controller in communication with the RF energy source and the manipulator, adapted to control operation of the manipulator and the electrode in accordance with a mode of operation that includes at least the following steps:
a) delivering RF energy to the electrode from the RF energy source sufficient to cause ablation of a tissue, and
b) moving the electrode so as to at least diminish adherence of tissue to the electrode.
In accordance with a preferred embodiment of the present invention the electrode has a longitudinal axis and the manipulator is adapted to move the electrode generally along the longitudinal axis.
Further in accordance with a preferred embodiment of the present invention the manipulator is adapted to move the electrode in a reciprocating movement.
Still further in accordance with a preferred embodiment of the present invention the manipulator is adapted to vibrate the electrode in at least two directions.
Additionally in accordance with a preferred embodiment of the present invention the electrode includes an insulating support, and the electrode and insulating support are configured as an electrode assembly that has a generally helical shape.
In accordance with a preferred embodiment of the present invention the manipulator is adapted to screw the electrode assembly into a tissue, wherein the electrode is adapted to cut a helical path into the tissue. The manipulator is preferably adapted to move the electrode back and forth along the helical path.
Further in accordance with a preferred embodiment of the present invention a plurality of the electrode assemblies are provided. A helical pitch of one of the electrode assemblies may be shifted axially with respect to a helical pitch of another of the electrode assemblies.
Still further in accordance with a preferred embodiment of the present invention the electrode has a generally hollow lumen formed therein.
Additionally in accordance with a preferred embodiment of the present invention a fluid source is in fluid communication with the lumen, wherein the lumen is formed with at least one outlet for passage therethrough of the fluid.
In accordance with a preferred embodiment of the present invention imaging apparatus is in communication with the manipulator and/or the controller, the imaging apparatus being adapted to sense motion of the electrode.
Further in accordance with a preferred embodiment of the present invention a central rod passes through a helix of the electrode. The central rod may be electrically conducting or insulating.
In accordance with a preferred embodiment of the present invention a sensor is placed at a distal portion of the electrode, the sensor being in communication with the controller.
Further in accordance with a preferred embodiment of the present invention one of the electrode assemblies is disposed within an inner volume of another of the electrode assemblies. One of the electrode assemblies may be concentric or eccentric with another of the electrode assemblies.